Subcontractor and Material Supplier Declaration
Suite 101 Harbourt Hall • 615 Loop Road • P.O. Box 5190 • Kent, Ohio 44242-0001
v: 330-672-3880 • f: 330-672-2648 •
web site: www.kent.edu/universityarchitect
OFFICE OF THE
UNIVERSITY ARCHITECT
The intent of this form is to confirm the companies submitted have been reviewed, appear to be Responsible, and are proposing to provide the services/material goods listed in compliance
with the Contract Documents. If the Project is administered using OAKS CI, use this form to gather information, and then enter it into the OAKS CI “Subcontractor Supplier
Declaration” business process in lieu of this paper form.
Instructions
M. Complete “EDGE Status” section. See the EDGE Web site for any questions at
www.EDGE.ohio.gov: Attach to this form their EDGE Certificate and
completed EDGE Affidavit.
Certified = EDGE-certified by Equal Opportunity Division (EOD).
Pending = EDGE application submitted to EOD and waiting for response.
Mentor = Special category of participation within the EDGE program.
Protégé = Special category of participation within the EDGE program.
N. Certify form by signing in the space provided and e-mail or fax to the A/E, and
KSU-OUA for review.
1. Kent State University (KSU-OUA) Initial Responsibilities:
A.
B.
C.
Complete Contractor Information section at top of the form.
Complete Project Information section at top of the form.
Issue to the Contractor via CD-ROM mailing.
2. Contractor Responsibilities:
A.
B.
C.
Use the form provided by KSU-OUA as a master for the project. Creation of
additional pages electronically or by photocopying is permitted. (Put cursor
over each grey block and then type to fill in your information).
Complete all required information for each Subcontractor and Material
Supplier. (Attach additional sheets as necessary.) Lower tier Subcontractors
who may provide on-site labor must be identified as Subcontractors.
Check company type as a Subcontractor, Material Supplier or Consultant.
D.
Enter company name, address, phone number, fax number, Federal Tax I.D.
Number and e-mail address.
E.
F.
Indicate the primary company officer (President, Owner) and contact person.
Attach the completed “State of Ohio Subcontract Form” with Exhibits for
each Subcontractor and Material Supplier.
Enter the date and amount of the Subcontract and/or Purchase Order.
Enter a brief description of the type of work to be performed by the
Subcontractor. Enter a brief description of the services/material brands being
supplied by the company. Attach additional sheets as necessary.
Enter the Subcontractor’s Skilled Trades License Number and attach a copy of
their unexpired Skilled Trades License.
Attach Subcontractor’s completed “Payroll Schedule” form.
Complete “DFSP Enrolled” section. Contractors, Subcontractors and Material
Suppliers providing labor on a state construction project site must be enrolled
in the OBWC Drug-Free Safety Program (DFSP) or BWC-approved DFSP
prior to performing work on the site. Submit supporting documentation
demonstrating approval status for an OBWC-approved DFSP. Attach to this
form proof of enrollment of all Subcontractors and Material Suppliers
providing labor on the project. Print out results via the OBWC Web site:
G.
H.
I.
J.
K.
3. A/E Review:
A.
B.
4. CM Review, if applicable:
A.
B.
C.
A.
B.
Enter the OBWC-approved DFSP policy number.
SAO-F310-01v0112
1
Attach additional sheets as necessary.
Review form in collaboration with the A/E and KSU-OUA.
When consensus is reached, receive the form from the A/E, sign in the space
provided, and e-mail or fax the form to KSU-OUA.
The CM must sign the same form the A/E has signed.
5. KSU-OUA Approval:
https://www.ohiobwc.com/employer/services/StateContract/nlbwc/StateContract1.asp
L.
Review form in collaboration with CM if applicable, and KSU-OUA.
When consensus is reached, sign in the space provided and e-mail or fax the
form to KSU-OUA or CM if applicable.
2
Check all that apply.
Verify all supporting documentation has been provided and is accurate.
Complete “For KSU-OUA Use Only” section in the order indicated below
1. Determine status of companies listed on each sheet received.
a. When one or more companies require “Extended Review”: mark
company status for each, and then go to C2.
b. When one or more companies are rejected: mark company status for
each, and then go to C3.
c. When all companies are approved: mark company status for each,
and then go to C4.
2. Forward a copy of the annotated form to the Contractor as its notice of the
Extended Review; then, proceed to perform and complete the Extended
Review. When completed, mark form as appropriate, and process per C1b
or C1c.
3. Prepare written documentation of basis for rejection and insert it into the
project file, and if appropriate, insert a copy into the “responsibility review
file” for the particular company; and then go to C4.
4. Forward a copy of the annotated form to the A/E, Contractor, and CM if
applicable. Insert the original form into the “Project file.”
Page 1 of 2
Subcontractor and Material Supplier Declaration
Suite 101 Harbourt Hall • 615 Loop Road • P.O. Box 5190 • Kent, Ohio 44242-0001
OFFICE OF THE
UNIVERSITY ARCHITECT
v: 330-672-3880 • f: 330-672-2648 • web site: www.kent.edu/universityarchitect
Contractor Information
Company Name
Address
City, State, Zip
Federal Tax I.D. No.
; Phone: (
)
-
Subcontractor
Company Name
Street Address
City/State/Zip
Telephone No.
Fax No.
Federal Tax I.D. No.
E-mail Address
Primary Officer
(
(
Contact Person
Subcontractor/Supplier + attach SoO Subcontract Form/Exhibits
Date of Subcontract or Date of Purchase Order
Amount of the Subcontract or PO Value $
Services/Material Brands1
Subcontractor Skilled Trades License No. + attach State License
Payroll Schedule attached? + attach Payroll Schedule
OBWC-approved DFSP in Good Standing + with OBWC proof
OBWC-approved DFSP Policy No.
EDGE Status2- + attach EDGE Certificate and EDGE Affidavit
For KSU-OUA Use Only
Sheet1
Project Information
Project No.
KSUProject Location
Kent State University
Project Name
Type of Contract
General Contract - 01
)
)
Material Supplier
(check one)
Yes
Campus
Consultant
-
Subcontractor or
Supplier to this Company?
Declare Third-Tier Company information below:
(
(
No
)
)
-
Yes
$
of
No
$
Yes
No
(when supplying labor on site)
Yes
No
Yes
No
(when supplying labor on site)
Yes
No (when supplying labor on site)
Certified
Approved
Pending
Mentor
Extended Review
Protégé
Certified
Rejected
Approved
(when supplying labor on site)
Pending
Mentor
Extended Review
Protégé
Rejected
Contractor Certification
Project Architect/Engineer Review
KSU-OUA Project Manager Review
Associate Director KSU-OUA Approval
Prime Contractor certifies that the information
above is true and complete.
Project A/E has reviewed the information above and
finds it in compliance with the Contract Documents
as shown or as noted.
-
KSU-OUA Project Manager has reviewed the
information above and finds it in compliance with
the Contract Documents as shown or as noted.
-
Subcontractors and Material Suppliers are
accepted, as shown or as noted, for use on this
project subject to revocation for cause.
-
Signature
Signature
Signature
-
Signature
Date
-
Date
Date
Date
If the Project is being administered using OAKS CI, then use this form to gather all required information first,
and then enter it into the OAKS CI “Subcontractor Supplier Declaration” business process in lieu of this paper form.
Kent State University Office of the University Architect Subcontractor and Material Supplier Declaration
1
Attach additional sheets as necessary.
2
Check all that apply.
Page 2 of 2